Juror Questionnaire Form printable pdf download

IN THE DISTRICT COURT OF _______________ COUNTY, KANSAS

You have been selected to serve as a juror in the District Court of _______________ County. Kansas law requires you to answer the questions on this form

and return it in the enclosed addressed, stamped envelope within the next seven days. The juror questionnaire is not a public record and is only made available to

court personnel and the attorneys and parties to the case being tried. Your cooperation and willingness to serve as a juror are appreciated.

It is Judicial Branch policy to comply with the Americans with Disabilities Act. If you have questions or concerns about jury service or if you are a person

with a disability needing a reasonable accommodation to serve on a jury, please contact the court clerk promptly after receiving the summons. The clerk may be

contacted by telephone at (XXX) XXX-XXXX or via the Kansas Relay Center at (XXX) XXX-XXXX.

JUROR QUESTIONNAIRE

IMPORTANT: Regardless of your personal situation, all Juror Questionnaires must be returned for processing in a timely manner!

Name:________________________________________

Round trip mileage from your

residence to the courthouse?

___________________

Last, First MI

Address:______________________________________

City:__________________ ST:______ Zip:___________

Statutory Qualifications

___

Yes

No__

Are you able to understand the

Length of residence in Kansas? __________

Length of residence in _____ County? __________

English language?

_____ _____

Home Ph:_______________ Work Ph:_______________

Are you at least 18 years of age?

_____ _____

Cell Ph: _________________

Are you a citizen of the United

Date of Birth:____________________ Age:__________

States?

_____ _____

______ Male

______Female

Are you a resident of __________

County?

_____ _____

_____Married _____ Separated _____ Divorced

______ Widower ______Single

Has a court found you to be

presently incompetent?

_____ _____

No. of Dependents:______ Ages:______________

Have you been convicted or pleaded

Circle highest grade of education completed:

guilty or nolo contendere to a felony

6 7 8 9 10 11 12 GED +1 +2 +3 +4

within the last 10 years?

_____ _____

Have you had vocational or professional training?

____No ____ Yes

If yes, explain:_________________

Have you served as a juror in this

county within the last 12 months?

_____ _____

Occupation:____________________________________

Employer:_____________________________________

Are you a breastfeeding mother?

_____ _____

If retired, answer the preceding two questions with information

from your last employment and check here: ________

If you believe you should be excused from serving as a

juror, please state your reason: ____________________

Spouse’s Name:________________________________

_____________________________________________

Spouse’s Occupation:____________________________

_____________________________________________

Spouse’s Employer:______________________________

Have you or any member of your immediate family

I affirm that the answers I have given to the questions

been party to any lawsuits? ______Yes ______ No

on this page are true and correct.

If yes, where and what type of lawsuit? _____________

_____________________________________________

Signed: ______________________________________

Have you ever served on a civil jury? __________

Dated: _______________________________________

Have you ever served on a criminal jury? __________

Juror Questionnaire Form

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